MEDICARE: KIDS SMILE, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	18580	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871754978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS SMILE, PC

Provider Business Mailing Address
First Line	:	315 N SAN SABA
Second Line	:	SUITE#1220
City	:	SAN ANTONIO
State	:	TX
Zip	:	78207-3154
Country	:	US
Telephone Number	:	210-225-8888
Fax Number	:	210-225-4195

Provider Business Practice Location Address
First Line	:	315 N SAN SABA
Second Line	:	SUITE #1220
City	:	SAN ANTONIO
State	:	TX
Zip	:	78207-3154
Country	:	US
Telephone Number	:	210-225-8888
Fax Number	:	210-225-4195

Authorized Official
Title or Position	:	OWNER
Name	:	MAURICIO MARCUSHAMER
Credential	:	DDS
Telephone Number	:	210-225-8888

Provider Enumeration Date	:	06/20/2008
Last Update Date	:	06/20/2008

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Directions to “KIDS SMILE, PC ” Practice Location

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